Notes from a Gram Sabha

Last week I was asked to attend the Aam Sabha betek, that is, bi-yearly meeting of the Gram Panchayat, in the village of Suralgaon. I had never been to Suralgaon. In terms of preventive health organizing, it is not one of the villages where CHIRAG is active. Kundun da, the Gram Pradhan had asked me to come to help organize the health committee that the panchayat had formed on its own. I thought it was a pretty cool opportunity, even if it meant me going on my own, and subjecting the villagers of Suralgaon to my still rough Hindi.

After ten months however, of organizing with communities on public health issues, trying to build a culture of action and prevention, and struggling to try and make some impact, I felt that just maybe, whatever I could bring from my experiences could be of some possible benefit.

When I arrived, the meeting had already started and I sat and listened as several different issues were discussed. The room was full, with around 40 people sitting tightly on the floor of a village community center. The majority of discussion revolved around water, or rather the dangerously low amount of water available these days (see New World Water). The lack of water actually has been a huge problem here, with the monsoons already delayed by more than two weeks. The talk was of hand pumps, and setting pipelines, and trying to manage with what little water was available in the village.

The discussion moved to encompass certain government yoganas (schemes), including the National Rural Employment Guarantee Act (NREGA), a legal guarantee of 100 days of employment doing public work. The act is aimed to benefit the rural poor through providing work at the fixed minimum wage. Government programs to assist local farmers were also introduced by the Gram Vikas Adhikari, a government representative from the block level. Different sorts of issues were raised, as well. One man brought up the fact that there was no footpath that goes to his house, and whether the panchayat would be able to help facilitate the construction of one.

After half an hour of listening Kundun da asked me to introduce myself and talk about the work I have been doing. Once more, in my imperfect Hindi, I jumped into the role of community organizer, rural India style. I explained who I was, the work that has been ongoing with health committees in neighboring villages, and the potential of communities coming to together to improve public health. It was a sort of all-in-one workshop, information, and planning session.

Afterwards, I facilitated the creation of a yearlong action plan to tackle health issues ranging from waterborne illnesses, to leucorrhea, to anemia, as community members discussed what should be done when. I’ve reached the point in my fellowship year, where I can at least do this much.

On the walk back from Suralgaon, it felt like one of those days that seemed to make some sense. And the days certainly alternate, often bringing sharp thoughts of what have I actually done here? But all of that is for another time (coming soon I reckon). For now, what is more interesting is thinking about the concept of democratic grassroots institutions, actively working for the improvement of their own community. To witness this process here, however imperfect – with problems of male dominance and money-driven plans, is still stimulating in a way that goes beyond politics and panchayats in rural India. It is the possibility of individuals, where ever they may be, working together towards civic engagement and social change.

It is from the results of such collective action and community ownership, through the vibrancy and creativity our lives inherently deserve, that we can shape our own realities and futures. And that can be translated across borders and languages, throughout communities, from rural India to wasteland suburbia.

National Rural Health Missing?

National Rural Health Missing?

“This is activism."
“This is what I know how to do.”

Since my arrival last September in Kumaon, at the foothills of Himalaya, the focus of my efforts has been working to address issues of public health with local communities. This has mainly involved organizing alongside Gram Panchayats. Gram Panchayats are elected local village councils that deal with social, economic, and developmental issues of the community. The Panchayati Raj system is backed by the Indian Constitution, which gives certain responsibilities and authority to panchayats to address issues of social justice and development. Since September I have seen my work slowly moving along, progress and small victories here and there, but it certainly hasn’t been easy. It’s involved a lot of patience, waiting for people to get on board, both in the communities and NGO, for meetings to start and action to be taken. It’s involved a lot of walking, up and down hills, across streams and through villages, at times for eight, ten, twelve kilometers a day. And it has included an immense amount of learning – about rural India, development, public health, village governance, and myself. It’s the type of work where the results don’t necessarily show in any sort of immediate timeframe and the questions only increase as time goes on. And honestly, every so often I have found myself questioning what impact I am having. In the long run, are these efforts I am undertaking enough to make a difference? Sometimes I wonder. But enough about me, what about rural health?

In brief, over the past eight months the process I have been helping with has involved forming health committees through village panchayats, providing trainings and workshops to these committees on their roles, responsibilities and rights, identifying main health issues and problems, writing out yearlong action plans to address the major health issues identified, and beginning the implementation of these plans. The issues range from anemia to waterborne illnesses (diarrhea, jaundice, typhoid, worms) to women’s health problems such as leucorrhoea. Importance is placed on antenatal care and on child health, specifically, ensuring that children are receiving the proper vaccinations. Health committees also address basic hygiene, cleanliness, and sanitation. This type of organizing has also included ASHAs (Accredited Social Health Activist) and ANMs (Auxiliary Nursing Midwife), in short government health workers that in different capacities work to address various health-related issues in villages. And in recent months implementation of the action plans drafted by health committees has begun. De-worming tablets have been requested by health committees and distributed, hemoglobin tests to check for anemia have been done, and springs and water tanks have been cleaned to help combat waterborne illnesses. Health camps on leucorrhoea have been planned and letters to the block and district levels have been sent.

Here’s one really quick anecdotal example of something that’s been achieved. For up to two years in many villages Iron Folic Acid (IFA) tablets have not been available through local government health supplies. It is strongly recommended that pregnant women take 100 tablets while they are pregnant (200 if they are anemic as well). In an attempt to get IFA tablets restored I spearheaded a campaign where Gram Pradhans and health committees sent multiple letters to both block and district health departments inquiring over the lack of IFA supply. Gram Pradhans even took up the issue at Block Development Committee meetings, a place where issues of health are never raised. Four months after the initial letter was sent word came from the Chief Medical Officer of the entire district that IFA supply would be restored for the entire Ramgarh block, and has now reached the majority of villages. A similar campaign was initiated to restore the supply of Vitamin A dose for children, which has been absent for almost three years. A couple days ago a letter from the CMO arrived informing CHIRAG (the NGO) and Gram Panchayats that Vitamin A is also being fully restored to the entire block. Chalk two up in our column.

All of these efforts have been within the larger context and framework of the National Rural Health Mission (get it? Mission, Missing. I thought it was kinda clever…), an Indian central government program initiated in 2005 to better attend to health in rural parts of the country through a number of different programs. While the NRHM covers the entire country, there is special concentration on 18 high-focus states (including Uttarakhand) “where the challenge is the greatest.” The NRHM specifically focuses on a decentralized approach that gives much decision-making and planning power to the grassroots level through village panchayats. In theory, action plans made at the village level are supposed to help determine the block’s, and in turn, the district’s health agenda. The idea is to empower communities to take ownership over public health in their villages. Another portion of the NRHM is the realization of Indian Public Health Standards, which aim to improve the level of government health service delivery. While on paper the NRHM may seem quite solid in its approach, the reality on the ground is much different and in remote areas there are still many challenges to be faced.

As the opening steps of implementation of these action plans unfold and village communities and health committees slowly become more familiar with health issues and use to the idea of taking action on these issues, there’s another idea I have had. The reality is that when illnesses or health problems strike, the majority of people make the several hour trips to the nearest towns of Haldwani, Bhowali, Almora, or Nainital. While more local facilities exist they are often underused and under-stocked. For smaller illnesses and injuries these local sub-centres can play an important role. As I see it, along with implementation of action plans, health committees could visit sub-centres to see what supplies and facilities are and are not available. Equipped with a list of what should be present, according to Indian Public Health Standards, such a visit would firstly familiarize committees and villages with what is available at their local centers, and secondly provide a platform for these committees to place pressure in order to ensure that the facilities and supplies that they are due will arrive. At this point I’d like to note that this is not to put all the blame on local government facilities or on the staff that work there. Nor is this is to say that the state is doing nothing. While health issues have not received the urgency they deserve, and there has been a slow response, some efforts have been made to address health. One example is 108, an emergency ambulance (and fire/police) service that has been introduced as part of the NRHM, is functioning fully in this area, and is used frequently (especially for deliveries). Even the name of this piece is posing a question. And the response is clear that things are gradually happening to address health and clear that there is plenty more to be done.

In my very-much-so imperfect Hindi what I have been pushing for with my colleagues and with committee members alike is for a more pro-active stance in seeing that health facilities provide what is needed. “­Dekho, apne aap kuch nahin hota. Thora sa dabana, thora sa hilana, phir kuch ho jayega. Agar log awaaz nahin uthayenge toh sarkar sochegi ki subkuch thik hai. Koi dikkhet nahin hai. Aur ye jhagara ke baath nahin hai. Ye apka adhikar hai. Aur ye main nahin bol raha hun, CHIRAG nahin bol raha hai, sarkar bol rahi hai ye sare subidha hona. Humen sirif dekhna kya hai or kya nahin hai. Phir is jankari ke saath hum kuch kar sakhate hai” (“Look, nothing happens on it’s own. You have to put a little pressure then things will happen. If people don’t raise their voice the government will think everything is fine. There’s no problem. And this isn’t about fighting. These are your rights. And I am not saying these facilities should be there, CHIRAG isn’t saying it, the government is saying all these facilities should be there. We’re just seeing what’s there and what’s not. Then with this information we can do something”). And so these visits have been planned. At this point it’s not entirely clear if it all will go as planned (but rarely is it ever). What happens from here and how successful this campaign will be are still to be determined – both in the short term and in the long run. Stay tuned though, and I’ll try and keep you posted.

So when my friend and colleague Manish points out that this approach I am encouraging is “activism”, I don’t know what to think. Maybe he’s right. But what are we talking about here? We’re talking about people following up on what is guaranteed to them. We’re talking about be able to have your blood pressure or hemoglobin count checked. We’re talking about pregnant women having access to Iron Folic Acid tablets, and communities being able to purify water with chlorine tablets. The ability to perform a safe delivery outside of a hospital, in an area where the majority of deliveries still happen at home. We’re talking about access to the basics. What I do know is that the background I am coming from is one of student organizing and social justice activism (in Washington DC and more so the surrounding suburbs, a context that is completely different from where I find myself now). And Manish is right when he goes on to say that it’s not necessarily the approach people are use to, but lets not forget that this is also the land of the Chipko movement and of Mahila Mangal Dal.

In any case, it’s been one way I have found myself engaging in my project and trying to build something here. Aside from being slow, and frustrating at times, there are moments where these ideas can also be exciting. Amongst communities and committees interest has been sparked and that spark has led to a little excitement from time to time of my own. It’s exciting to feel the potential of panchayats organizing around issues they haven’t normally done so in the past. Traditionally in this region panchayats have focused on physical development –building roads, sidewalks, and water tanks. Soft-development areas like health or education are relatively new, uncharted territory. This is the first time in this region that panchayats and communities are coming together in this way to address health. It’s been reassuring to see the priority women’s health has taken in this process, as issues of leucorrhoea, anemia, and maternal health, have been recognized as issues that must be addressed. What is more encouraging is that men have been active in identifying women’s health issues and pushing for them to be tackled in what remains a rather patriarchical society. And the moments I am able to see my work and time here through this lens, it’s pretty cool. To be a part of this course, though still in the opening steps, in a process that will take years and years. And it’s meaningful to me to be doing it here, however small my contribution in the larger picture, in rural India. In this corner of the world, in this place, which over the past so many months has become familiar. And if I may remind you, it is health we’re addressing, a fundamental human right, and a fundamental human need.

New World Water

From rural Himalayan villages to urban city slums one lasting notion that has stayed with me throughout my Indicorps fellowship year thus far has been the importance of water for a healthy and prosperous existence on this planet. Now maybe this sounds all too obvious and it doesn’t take a year of service in India to figure out water is important. But seeing just how important water is, and what issues arise when there is a lack of clean water has been striking. Maybe it's been being in a rural area working alongside communities with an NGO that has its hand in everything from health to forestry to education. A part of it certainly has been living in villages and seeing what lengths are taken everyday to simply collect water to use for cooking, and cleaning, and drinking. It’s been seeing the importance of proper sanitation; or rather the immense accumulation of waste from a lack of proper sanitation, in settings like the slums of Kanpur and the city of Ahmedabad. And it’s been the work I have been doing – a village governance and public health project, and hearing about the high instances of water-borne illnesses like jaundice, diarrhea and typhoid. Or maybe it's just been after all of this, taking into account what many of us take for granted. Whatever combination of these experiences it may be; seeing the effect of a lack of clean water on communities brings up certain questions. Questions like, given the stark realities related to a lack of clean drinking water and proper sanitation shouldn’t access be ensured as a fundamental human need? If water is so precious then do those of us who enjoy easy access to it have a responsibility to conserve it? And do we presuppose our inherent right to water, a limited natural resource, while so many others struggle without such availability?

Apart from being an NRI who has grown up in the DC suburbs, and an Indicorps fellow who has been riding the highs, lows, successes and frustrations of a year of service in rural India, amongst other things I would have to identify myself as a hip-hop head of sorts (I even was an emcee in a couple bands in high school, surely that’s got to count for something?). Now obviously what immediately comes to mind in this rumination on water is track nine from 1999’s Black on Both Sides by Mos Def (an incredible album, first track to last), New World Water. Putting aside the politics of hip-hop, the song is on-point as Mos narrates, well, new world water (I know right, I was thinking the same, how fitting for this piece). Now to some it may seem like a little bit of a stretch to relate the experiences and realities of working for change in rural India with Brooklyn-born-and-bred lyrics, but I feel the connection is quite simple, and if you bear with me, in a way sort of insightful. The origins of hip-hop music come from a place of providing a voice to those who are not always heard, a place that challenges and critiques the social problems of our society, and a venue to mix poetry and politics. A place to provoke thought and discussion; a space to engage in and initiate social change. And you know what, fine, if it doesn’t work for you then merely accept this as an extension of my own multi-hyphenated identity. But really, aside from blazing break-beats and raw, speak-truth-to-power-in-yo-face lyrics it’s this unabashed, unapologetic rejection of accepting the status quo that I fell in love with as a kid. And the kids these days you know, this hip-hop stuff, they really love it.

“Man, you gotta cook with it, bathe and clean with it/When it's hot, summertime you fiend for it” While living with a family in the village of Simayal, most mornings I would descend down from the house I was staying in to fill a carton of water from a water tank in the village. This was the easy part. The steep trek back up with gallons of water situated on my shoulders would unfailingly leave me sweating, despite it being the middle of December. I figured it was the least I could do to help out as I too used the water to wash my clothes, to bathe with, and in the food that was prepared. While I made that trip usually once a morning, it was repeated seven or eight times everyday. Just knowing that made me conscious of the water I used whether it was to brush my teeth or wash my dishes (which I mean, honestly isn’t the case now with the tap I use in my current living arrangement). I began to depart on these morning pilgrimages for water once the rainwater tank had run out. Outside the house there was an underground tank that held water collected during the monsoons. This rainwater harvesting allows for a large amount of water to be stored, and conserved. Yeah, it’s pretty cool stuff. By the end of my stay with the family I had gotten use to my daily routine, but in the last days the outdoor water faucet by the house started to provide a couple hours of water every morning. Now I would reckon that most of the people who end up reading this may struggle to fully imagine and recognize the fact that in many places in India water is only available for a couple hours a day. To use water often involves first carrying it from a long distance, and especially in a hilly region, to collect water requires a physically strenuous task, a task that often is assigned to women.

“You can laugh and take it as a joke if you wanna/But it don't rain for four weeks some summers” In rural Kumaon, and most agricultural communities, water from the sky above is an integral part for sustenance. In particular, precipitation is counted on for the livelihoods of the majority of the population – farmers. Both too little rain, and too much rain can negatively impact crop yield, and many, many lives in turn. But merely precipitation alone is not required. The reality here in this part of Kumaon, like many places in the world, is that there is a significant shortage of water. This can be attributed to several main reasons, one being deforestation. While the state of Uttarakhand boasts one of the best forest covers in all of India, forests have steadily been declining, which has led to a drop in the water table. It’s sort of like this you see, due to deforestation there is less infiltration in the ground that leads to soil erosion, which means less soil depth. This leads to lower recharge of water in the ground, which means lower discharge (my shit isn’t that hot, I had to have this explained to me more than once). Climate change also plays a part in less precipitation. For example, this winter I mean it was cold, but given the Himalayan setting it was quite mild. It rained maybe once or twice, and only snowed once, an actuality that was constantly deplored by the local population. And this is not the first year such a phenomenon has occurred in an area that is use to receiving much more severe winters. Lastly, this being such a stunning area an influx of hotels and hi-fi summer homes has cropped up throughout the region. The luxuries such places have include the ability to switch on and off water from a tap or shower at will. The increased level of consumption that these hotels and homes bring has placed strain on springs that are the source for water in the area.

Now don’t get me wrong. It wouldn’t be fair depict those coming from abroad or urban India as totally insensitive to water, and try and give off the idea of everyone here as water-conscious sadhus. There are many a day when I see water faucets in villages that are left running or that simply cannot be shut off. But real quick, back to this idea of consumption, now that’s a familiar one. What you got for me Mos? “Americans be wastin’ it on some leisure shit, while other nations be desperately seekin’ it.” The population of the United States accounts for less than 5% of the world’s population yet consumes approximately 25% of the world’s fossil fuels. In regards to water, inefficiency and a lack of infrastructure in developing nations can lead to high per-capita withdrawals, just as high or higher than in developed countries. Still, according to the UN Development Report (2006) the average North American uses 400 liters a day, the average European 200 liters. This is in comparison to the “average person in the developing world uses 10 liters of water every day for their drinking, washing and cooking” (Water Supply and Sanitation Collaborative Council). The reality remains that around one billion people today lack access to decent access to safe drinking water. I can remember the days of twenty-minute hot showers, sprinklers running non-stop in every other suburban yard, and the tap running as I shaved or brushed my teeth. The question is, should be doing more to consume less?

And when was the last time that we had serious reason to worry about getting sick from the water we consume everyday? Through my efforts here it has become quite clear that waterborne illnesses are a very real problem that affect every single village I have organized alongside. Related to water, these efforts have included conducting water tests, trying to secure supplies of chlorine tablets and bleaching powder from local government health facilities, and organizing health committees to clean village water tanks and provide de-worming tablets. Specifically, the instances of water-borne illnesses increase dramatically during the summer and monsoons, and as the season is approaching I am currently in the process of trying to launch an awareness campaign about purifying water through chlorination and boiling. According to UNICEF, “a lack of safe water and sanitation is the world’s single largest cause of illness.” The same report goes on to state that everyday approximately “4,500 children die from unsafe water and lack of basic sanitation facilities.” And that’s not to discount the lead in DC pipes, but even then boiling water does not include burning the precious wood and other forms of fuel that has been back-breakingly collected.

One of the United Nations Millennium Development Goals includes “halving, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation.” In recent years there have been a number of campaigns pushing to have clean water explicitly recognized as a fundamental human right and ensure that people everywhere can cheaply access it. And if this wasn’t enough to try and process at once, there are other looming questions to be addressed regarding water as a fundamental right, and the effects of its privatization. “Used to be free now it cost you a fee/Cause it's all about gettin’ that cash money” In many places in the world, India included, privatization of water has been met with fierce opposition by civil society groups, NGOs, and activists. Critics cite that privatization may lead to profits being placed over people’s needs, gives too much control and preference to multinational corporations over an essential human need, and further disadvantages poor and marginalized populations (those that don’t have a hook-up with municipal water facilities). Another criticism that is levied against the privatization of water is that privatization is often imposed by international economic institutions (like the World Bank and IMF) through neo-liberal policies, at the expense of the developing world.

There is a fear that if water is commodified then only those who can afford it will have proper access to it. And maybe that is already beginning to happen. Like access to decent education and health, water is a basic necessity for a thriving human existence, one that every human being would like to have, and one that rights-based conventions and declarations seek to ensure. A report by The Office of the UN High Commissioner for Human Rights concludes by stating, “It is now time to consider access to safe drinking water and sanitation as a human right, defined as the right to equal and non-discriminatory access to a sufficient amount of safe drinking water for personal and domestic uses - drinking, personal sanitation, washing of clothes, food preparation and personal and household hygiene - to sustain life and health.” Proper access to clean drinking and sanitation is required for a healthy life, a life with dignity. It seems maybe a bit odd then to profit off of water when there is such a dire need for it in many places of the world. Especially, when we do not respect the limited resource water is, as we pollute and waste, not heeding calls to conserve. But at the same time there are those individuals and entities that profit off of this type of commodification. “The type of cats who pollute the whole shore line/Have it purified, sell it for a dollar twenty-five” But maybe I digress.

And so after all of this hullabaloo I’d say the magnitude of water should not be downplayed, whether we recognize it from the subcontinent or clever rap lyrics. Obviously there are many more questions than what I have simplistically tried to put out there in this brief discourse. And while there may not be easy answers to all of the questions regarding the larger issues of water consumption, there are easy steps we can take to consume less, possibly the first being, simply being aware of how important water is the world over. So I humbly request that you accept these written bars as some food for thought. But to tell it best I defer to Mighty Mos, “Tell your crew to use the H2 in wise amounts/Since it’s the new world water, and every drop counts”